I am the medical director for a small fire/EMS agency which is growing exponentially. Until recently, I have been personally involved with each EMS provider before they were released to function independently. They knew that if there was a problem, it was up to just the two of us to take care of it. For better or for worse, that is no longer possible. The days where I personally provided all the continuing education and saw every provider at least monthly are gone, and it is more difficult to ingrain my philosophy as their medical director without this personal contact.

Over the past year, there have been several providers with sudden departures from our agency. Because of the nature of personnel confidentiality, management cannot divulge the circumstances, but the affected providers have told their colleagues that they left because of inappropriate EMS actions, which is grossly inaccurate. This has resulted in considerable anxiety recently about "screwing up" and getting fired for an EMS mistake.

I have great faith in the individuals who are charged with supervising, precepting and getting new providers ready to practice in our system, but there is a tendency to focus on details such as skills, protocols, and documentation. However, EMS is all about little problems and dilemmas that really require problem solving and application of knowledge, rather than fitting neatly into an algorithm. I put together some general principles, "Laws," to help the newer providers understand the big picture of EMS and make sure they see the forest and not just the trees.

Laws of EMS

1. Primum non nocere. First, do no harm. Just because you can do something, it doesn't mean you should. A number of the things that are considered cool to do in EMS are done infrequently and are risky procedures on critical patients. Don't be cool at the patient's expense. Don't cut a hole in someone's neck just because you can. Do it because it is the best management option for that patient, and you are confident in your ability to do it successfully.

2. Always be the patient's advocate. Treat them like your family - put yourself in their shoes or in their mind. It can be nearly impossible to remember this sometimes at 2 a.m., but somehow things that aren't a problem during daylight become frightening at night, and people call 9-1-1. The EMS Theory of Relativity can cause two months of abdominal pain to turn into potential appendicitis after a discussion with a relative, convincing the patient they need emergency surgery right now, even though you know better. Care, and have enough patience to talk to your patient long enough to find out what they are thinking and what frightened them. It often turns out that what initially seemed unimportant to you actually is a real problem.

3. Be honest, precise, prompt and professional with your patients and in your work habits. Be the kind of person you wish was taking care of your loved one. We all have bad days, and some of us have terrible black clouds. Your patient doesn't know about all the other misery you have encountered today - you are the one they are depending on to help in their time of need. Do your best.

4. The Diesel Principle: If you can't fix the problem, move the patient expeditiously toward someone that can or a group of people who have more experience and resources. If you are busy stabilizing the airway or supporting the patient's breathing, remember that waiting to start an IV doesn't improve oxygenation. So do it enroute, or let it go! If you are two blocks from the trauma center with a pedestrian struck, don't stay and play in the street. Rapid extricate straight to the trauma bay!

5. There is no shame in asking for help. If you need it, get it - but not at the expense of rule No. 4. It is probably silly to wait 15 minutes on scene for a helicopter or ALS assist when you can be in the trauma bay in 20 minutes by ground. From your perspective, when the ALS assist or helo arrives, to some degree it becomes someone else's problem - but from the patient's point of view, is this really going to help them more (from a time and care provided viewpoint) than expeditious transport to definitive care?

6. EMS is a team sport. Teams need captains, players, trainers, coaches and other support staff. The team doesn't work well if all the elements don't gel or if any of the members of the team think they can work alone, but keep in mind that every team needs a leader. Truly listen to your crew and/or colleagues, they are the extra set of eyes and hands that keep you and the patient safe. This applies to both work and personal life issues. Know your own strengths and weaknesses, as well as your team's, and work with what you have.

7. There is something to learn from every patient, and every single one of us has more to learn. That applies to physicians, too, as each of you knows. Be humble enough to admit you don't know it all, but be confident enough to apply the knowledge you have to unfamiliar situations.

8. Consistency is a virtue. So is reliance on facts instead of feelings. Your approach to patient assessment, documentation, checking your truck, etc etc, should be the same every time. It keeps you from forgetting or missing things, and more importantly, it keeps you from having excessive faith in what you believe to be true but cannot substantiate with facts. Always confirm the facts yourself things change and people lie, so don't take someone else's word for the important stuff.

9. If you are unsure what to do, generally you should choose to do more rather than less. If something makes the hair stand up on the back of your neck go with that feeling. It's usually right. Think of the consequences of your decision, and if that doesn't point you in the right direction, call and ask the EMS supervisor or medical command what you should do. Corollary: If you are unsure whether this is a BLS or ALS patient, err on the side of transporting with ALS care available. When you're not sure what's going on, don't spend time rationalizing to yourself why less is ok-if you are taking things (i.e. monitor) off the patient to ready them for transport or transfer to a lower level of care, you are likely making a mistake.

10. If something goes wrong, always confess early. This applies whether you actually or potentially screwed up, whether you think it was your fault or not or even if just something bad or strange happened that you don't think you had anything to do with. See rule No. 7. Getting all the information while it is fresh in everyone's mind can't be overestimated. The ability to review and deal with an issue one way or another within hours of the incident positively impacts provider morale, because there is a plan in place, and we can all move on without worrying about "what if?" If you honestly did the best you could under the circumstances, even if it turned out to be wrong, we will work together to deal with whatever problems are uncovered personal, educational, system, or situational.

The above laws apply to me as well, and I hope they will help us shape an excellent EMS system in the imperfect, unpredictable world we live and work in. Maybe you can use them in your system as well!